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  • AFO Orthometry Form Opt

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    aryoga
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    This document is an orthometry form for an ankle-foot orthosis (AFO) from Anatomical Concepts, Inc. It collects information such as the customer and patient's name, billing/shipping addresses, diagnosis, measurements, material choices, and special instructions for modifying or finishing the AFO. Standard turnaround time is 10-15 business days, but rush options are available for additional fees to receive the AFO within 2-5 or 6-9 business days.

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    This document is an orthometry form for an ankle-foot orthosis (AFO) from Anatomical Concepts, Inc. It collects information such as the customer and patient's name, billing/shipping addresses, diagnosis, measurements, material choices, and special instructions for modifying or finishing the AFO. Standard turnaround time is 10-15 business days, but rush options are available for additional fees to receive the AFO within 2-5 or 6-9 business days.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    31 views1 page

    AFO Orthometry Form Opt

    Uploaded by

    aryoga
    This document is an orthometry form for an ankle-foot orthosis (AFO) from Anatomical Concepts, Inc. It collects information such as the customer and patient's name, billing/shipping addresses, diagnosis, measurements, material choices, and special instructions for modifying or finishing the AFO. Standard turnaround time is 10-15 business days, but rush options are available for additional fees to receive the AFO within 2-5 or 6-9 business days.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 1

    AFO ORTHOMETRY FORM

    CUSTOMER NAME: ________________________________________ PATIENT NAME: __________________________________________

    BILL TO / SHIP TO: _________________________________________ AGE: _______ HT: ________ WT: ________ SEX: __________

    ADDRESS:_________________________________________________ DIAGNOSIS: ______________________________________________

    __________________________________________________________ PO# :_____________________________________________________

    PHONE: ______________________FAX:________________________ SHIPPING METHOD: _______________________________________

    CONTACT: _______________________________________________
    STANDARD TURNAROUND TIME: 10-15 BUSINESS DAYS
    EMAIL:__________________________________________________
    24 hrs-$100 ea 2-5 business days-$75 ea
    Rush Options:
    6-9 business days-$50 ea
    TRIM LINES

    PLS SEMI SOLID


    RIGHT LEG LEFT LEG BILATERAL
    ANKLE MOTION: FREE 90 STOP OTHER
    *******PLEASE CORRECT YOUR CAST IF NECESSARY!!!!!!!!
    PLANTAR STOPS: ELITE PLASTIC
    CORRECT CAST TO 90 DEGREES_______________________
    OTHER: ________________________________________________
    LEAVE CAST AS IS: ____________
    Footplate: FULL FOOT SULCUS PROX TO MTP
    CORRECT ANKLE VARUS/VALGUS TO NEUTRAL:____________ STRAPS
    REMARKS: _______________________________________________ HOOK & LOOP OR DACRON BACKED

    __________________________________________________________ COLOR: WHITE BLACK

    COPPER RIVETS SPEEDY RIVET SCREWS

    INSTEP STRAP
    MATERIALS
    MEASUREMENTS
    POLYPRO COPOLY

    THICKNESS: 1/8” 5/32” 3/16” • BOTTOM OF HEEL TO FIBULA HEAD


    (AFO HEIGHT):___________________________
    COLOR: NATURAL BLACK • FULL FOOT LENGTH: ________________
    • ANKLE M/L:_________________________
    LINER: UNLINED 1/8” 3/16” 1/4” • PROX CALF CIRC:____________________
    • MET HEAD WIDTH:___________________
    VOLARA TERRYCLOTH 3/8"

    SPECIAL INSTRUCTIONS [MODIFYING OR FINISHING]:


    ANKLE JOINTS
    ___________________________________________________
    TAMARACK OKLAHOMA
    ___________________________________________________

    ___________________________________________________
    ANATOMICAL CONCEPTS, INC
    1399 E. WESTERN RESERVE ROAD ___________________________________________________
    POLAND, OH. 44514
    ____________________________________________________
    P: 330-757-3569 / 800-837-3888
    F: 330-757-3634 / 800-657-7236
    Email: info@anatomicalconceptsinc.com
    **CASTS WILL BE SAVED FOR 30 DAYS UNLESS OTHERWISE
    REQUESTED.

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